Provider Demographics
NPI:1417909060
Name:REAGAN, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:REAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:209 CROSSROADS PL 150
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6546
Mailing Address - Country:US
Mailing Address - Phone:618-244-6710
Mailing Address - Fax:
Practice Address - Street 1:209 CROSSROADS PL
Practice Address - Street 2:SUITE 110
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6254
Practice Address - Country:US
Practice Address - Phone:618-244-6710
Practice Address - Fax:618-244-6779
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-064567208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10489Medicare PIN
ILC37421Medicare UPIN